What Do Your Choices Mean?

If you score in Level D in any area, your practice is just getting started and may want to review our resources page to help you prepare for the key changes described in that section of the guide.

If you score in Level C in any area, your practice is in the early stages of change and can benefit from the action steps and resources in that section of the guide.

If you score in Level B in any area, your practice has implemented basic changes and can build upon your success with the action steps and resources in that section of the guide.

If you scored in Level A in any area, your practice has achieved most or all of the important changes required. Congratulations! You can still use the actions steps and resources in that section of the guide to find new ways to improve.

What is the challenge?

Integrating care for mental, behavioral and psychosocial issues into primary care has become increasingly important. Many patients come to primary care seeking relief for physical symptoms that are related to mental, behavioral and psychosocial problems. Alternatively, illness can lead to depression, stress or other behavioral health issues. These problems generate both acute and chronic challenges for a busy practice. Mental or substance abuse disorders require close follow-up and evidence-based adjustment of treatment to reach clinical targets. Acutely distraught, agitated, or even violent patients regularly appear in primary care. Without ready access to behavioral health expertise, primary care providers and staff often feel unprepared to meet the needs of these patients, and may have to disrupt their clinic schedule and call for emergency assistance.

What needs to change?

Most primary care practices treat behavioral health as another consultative specialty accessed by referral. Relying on referrals to unaffiliated behavioral health providers, however, all too often leads to no-shows and communication and care coordination problems. For patients with mental health or substance abuse problems, outcomes are best when primary care and behavioral health integrate their care to:

Ensure ready access to assessment and management for patients in crisis.

Provide brief counseling for individuals who may need additional support for episodic issues.

There are many different ways to configure the behavioral health services of a primary care practice. Considerations include the morbidity and needs of the patient population, the nature of community resources, and reimbursement opportunities for behavioral health providers. A major decision is whether to co-locate or rely on relationships with outside BH providers.

Integrated services can be achieved by collaborative care arrangements with outside psychiatric/substance abuse consultants or by adding behavioral health provider(s) to the primary care practice team. Whether the behavioral health provider is located in the clinic or in an outside organization, full integration with primary care must include sharing care planning and health records; agreement on care pathways and guidelines; and ready access for patients with acute needs.

A Framework for Measuring Integration of Behavioral Health and Primary Care

Read more

This website presents a framework for understanding what behavioral health integration involves, from the AHRQ Integration Academy. Functional domains include care team expertise, clinical workflow, patient identification, patient and family engagement, treatment monitoring, data collection and use, and desired outcomes.

CareSouth Carolina Case Study

What do we gain by making these changes?

Practices that successfully implement collaborative care for depression and other chronic mental health disorders consistently report much higher rates of remission and recovery. Readily available and predictable crisis management services for distressed patients, whether by full integration, co-location, or via agreement with community-based behavioral health service providers, can give patients timely access to mental health expertise and provide relief for busy primary care teams. However, patients may be reluctant to seek help for behavioral health related issues for a number of reasons, including:

Stigma associated with seeing a behavioral health specialist.

Absence of insurance coverage for behavioral health services or lack of knowledge about benefits, due to complexity of how behavioral health benefits are administered in many organizations and/or states.

Having a behavioral health specialist integrated into primary care teams addresses many of these patient barriers. For example, patients are able to be seen at their primary care clinic, a location that does not specialize in mental health treatment and therefore reduces stigma and increases the patient accessibility to care.

Furthermore, there are many benefits to the team in having access to the consultation of a behavioral health specialist, both to boost the capacity of staff members to address behavioral health issues, and to support the primary care staff and teams to ensure healthy interpersonal relations and a supportive work environment.

Behavioral Health Integration Implementation Guide

Read more

Explore a range of resources available in the Behavioral Health Implementation Guide, compiled by the Safety Net Medical Home Initiative. The guide includes making the case for behavioral health integration and how it works, from implementation to sustainability. The information is relevant to all types of practices, not just those in the safety net.

Expanding Behavioral and Mental Health services to patients as part of the PCMH model of care

Behavioral health encompasses a wide array of services. Each practice organization needs to define the scope of behavioral health needs it wants to address in an integrated fashion. Does the practice feel confident that it can efficiently deal with acutely distressed patients? Is substance abuse expertise critical for your population? Does the scope include behavior change, like smoking cessation, improving medication adherence, goal setting for healthy eating and improving physical activity, or meeting common social needs? Nonetheless, essentially all primary care practices must have integrated strategies in place to effectively and efficiently deal with acutely distressed patients, and manage patients with chronic psychiatric disorders such as major depression.

View Resources

Clinical protocol

Scope of integrated behavioral health

This table presents the range of services that require a blend of behavioral health and medical expertise. It is part of a comprehensive resource from the Agency for Healthcare Research and Quality (AHRQ) Integration Academy: Lexicon for Behavioral Health and Primary Care Integration. http://integrationacademy.ahrq.gov/lexicon

Behavioral Health role functions and personnel who can perform them

This table presents behavioral health services in terms of the role functions and people who can perform them. Functions include screening, patient activation, crisis intervention, social support, and levels of behavioral health therapeutic interventions. A range of team members can fulfill each function. See how your MA, nurse, Behavioral Health specialist, and other roles can make important contributions.

How a practice tries to integrate behavioral health expertise will be influenced by practice size, payment options, patient population needs, and behavioral health resources in the community. Practices need to select behavioral health specialists and organizations with whom to collaborate, as well as the level of integration. Many practices find having a behavioral health specialist on-site attractive and reassuring because it facilitates warm handoffs. In addition to having a behavioral health specialist who can provide patient counseling (such as a masters-level therapist or psychologist) and potentially an addictions counselor, most practices will also need a psychiatric consultant for consultation on psychotropic medication management (a Psychiatrist or Psychiatric Nurse Practitioner). Consultation may not involve direct contact with the patient, as long as behavioral health specialists are willing to work in non-traditional ways with non-traditional payment arrangements.

Regardless of the approach, integrated care must also include a shared commitment to measurement-driven, treat-to-target care for chronic problems (see Step 3), as well as interactive communication and sharing of care among behavioral health and primary care providers. Choose a model that fits your organizational and community resources, but remember the importance of proximity and availability.

View Resources

Toolkits

Integrating Behavioral Health into Primary Care–models from around the country

This website offers a variety of case studies on behavioral health integration, compiled by SAMHSA.

Behavioral Health Care at Clinica Family Health Services

Watch this video about one LEAP site's approach to integrating behavioral health. Clinica Family Health Services focused on building a collaboration with local agencies, defining patient needs and services to meet each need, and getting the behavioral health professionals fully integrated into team "pods" and the EHR. You can also read about Clinica's behavioral health care model here.

Link to Behavioral Health Specialist module

To provide evidence-based collaborative care, the primary care team should have:

Explicit guidelines for the treatment of chronic mental health/substance abuse disorders, and standing orders that enable appropriate members of the care team to deliver evidence-based treatment and act independently.

The capability to provide care management services to patients.

Collaborative care is delivered by a team that includes the patient, the primary care provider, a care manager, and a Psychiatric consultant. The Care Manager supports the primary care provider by coordinating treatment, regularly monitoring treatment response, and alerting the provider when the patient is not improving. The professional background of the Care Manager varies depending on the staffing of the primary care clinic and the treatment regimen. RN and behavioral health specialist care managers can also evaluate and influence treatment, and facilitate communication with the psychiatric consultant regarding treatment changes. Behavioral Health specialist care managers can further add psychotherapy to the treatment regimen.

View Resources

Toolkits

Collaborative care resources

Find a wealth of tools and resources from the AIMS (Advancing Integrated Mental Health Solutions) Center at the University of Washington. The resource library allows you to search by care team member role, implementation tool, or type of resource. You can find guidelines for treatment, standardized instruments, training modules, and much more to equip your team to deliver collaborative care.

Behavioral Health Integration resources

Explore a range of resources available to guide an organized, evidence-based approach to behavioral health care, compiled by the Safety Net Medical Home Initiative. From this site, you can view case examples, tools, and webinars from primary care practices that have integrated behavioral health. The information is relevant to all types of practices, not just those in the safety net.

Nearly all LEAP sites found value in being able to obtain timely assessments and short-term therapy from co-located or affiliated behavioral health specialists. Some ways to foster warm handoffs include:

Behavioral Health Warm Hand off referral

This referral form helps facilitate warm hand-offs of patients from primary care providers to behavioral health specialists at one LEAP site, Asian Health Services. The front page summarizes the reasons for referral, and the back page shows the protocols that each team member should follow to ensure effective warm hand-offs.

High-quality integrated care requires effective teamwork with: clear roles and work processes, shared expectations and protocols, and effective communication approaches. It’s important to bring all members of the team together for training and discussion about working together. This is especially important for the primary care provider, behavioral health specialist, care manager, and psychiatric consultant to train as a team around collaborative care processes. The goals of their training include: agreement on treatment, treatment targets, assessment methods, and follow-up; criteria for hand-offs; and guidelines and strategies for communication.

View Resources

Staff training

Mental Health First Aid Training Curriculum

Just as cardiopulmonary resuscitation (CPR) helps people assist someone having a heart attack without any clinical training, Mental Health First Aid helps people address an acute mental health-related crisis. All team members at LEAP site Hidalgo Medical Centers receive training in Mental Health First Aid to learn risk factors and warning signs for mental health and substance use concerns, strategies for how to help someone in both crisis and non-crisis situations, and where to turn for help.

Tracking treatment and outcomes over time in patients with common disorders such as depression gives practices the information needed to treat to target. By measuring patient outcomes, providers can adjust therapy to reach clinical goals. The first steps are to:

Behavioral Health Integration Implementation Guide

Explore a range of resources available in the Behavioral Health Implementation Guide, compiled by the Safety Net Medical Home Initiative. The guide includes making the case for behavioral health integration and how it works, from implementation to sustainability. The information is relevant to all types of practices, not just those in the safety net.

Integrating Behavioral Health into Primary Care–models from around the country

Collaborative care resources

Find a wealth of tools and resources from the AIMS (Advancing Integrated Mental Health Solutions) Center at the University of Washington. The resource library allows you to search by care team member role, implementation tool, or type of resource. You can find guidelines for treatment, standardized instruments, training modules, and much more to equip your team to deliver collaborative care.

Scope of integrated behavioral health

This table presents the range of services that require a blend of behavioral health and medical expertise. It is part of a comprehensive resource from the Agency for Healthcare Research and Quality (AHRQ) Integration Academy: Lexicon for Behavioral Health and Primary Care Integration. http://integrationacademy.ahrq.gov/lexicon

Role featuresJob descriptions, career ladders and other HR materials

Role features

Behavioral Health role functions and personnel who can perform them

This table presents behavioral health services in terms of the role functions and people who can perform them. Functions include screening, patient activation, crisis intervention, social support, and levels of behavioral health therapeutic interventions. A range of team members can fulfill each function. See how your MA, nurse, Behavioral Health specialist, and other roles can make important contributions.

Video

Video

Behavioral Health Care at Clinica Family Health Services

Watch this video about one LEAP site's approach to integrating behavioral health. Clinica Family Health Services focused on building a collaboration with local agencies, defining patient needs and services to meet each need, and getting the behavioral health professionals fully integrated into team "pods" and the EHR. You can also read about Clinica's behavioral health care model here.

Behavioral Health Integration resources

Explore a range of resources available to guide an organized, evidence-based approach to behavioral health care, compiled by the Safety Net Medical Home Initiative. From this site, you can view case examples, tools, and webinars from primary care practices that have integrated behavioral health. The information is relevant to all types of practices, not just those in the safety net.

WorkflowTemplates, flow sheets and mapping aids

Workflow

Behavioral Health Warm Hand off referral

This referral form helps facilitate warm hand-offs of patients from primary care providers to behavioral health specialists at one LEAP site, Asian Health Services. The front page summarizes the reasons for referral, and the back page shows the protocols that each team member should follow to ensure effective warm hand-offs.

If you have a question about the improvements, action steps, or tools & resources in this module please let us know. We're here to help. And if we can't answer your question, we can probably connect you with someone who can.